Background

In response to the COVID-19 pandemic in the United States, in March, 2020, CDC recommended that dental settings should prioritize urgent and emergency visits* and delay elective visits and procedures to protect staff and preserve personal protective equipment and patient care supplies, as well as expand available hospital capacity. However, as the pandemic continues to evolve, and healthcare settings are responding to unique situations in their communities, CDC recognizes that dental settings may also need to deliver non-emergency dental care. Dental settings should balance the need to provide necessary services while minimizing risk to patients and dental healthcare personnel (DHCP)†. CDC has developed a framework for healthcare personnel and healthcare systems for delivery of non-emergent care during the COVID-19 pandemic. DHCP should regularly consult their state dental boards and state or local health departments for current local information for requirements specific to their jurisdictions, including recognizing the degree of community transmission and impact, and their region-specific recommendations.

Transmission: SARS-CoV-2, the virus that causes COVID-19, is thought to be spread primarily through respiratory droplets when an infected person coughs, sneezes, or talks. Airborne transmission from person-to-person over long distances is unlikely. However, COVID-19 is a new disease, and we are still learning about how it spreads and the severity of illness it causes. The virus has been shown to persist in aerosols for hours, and on some surfaces for days under laboratory conditions. COVID-19 may be spread by people who are not showing symptoms.

Risk: The practice of dentistry involves the use of rotary dental and surgical instruments, such as handpieces or ultrasonic scalers and air-water syringes. These instruments create a visible spray that can contain particle droplets of water, saliva, blood, microorganisms, and other debris. Surgical masks protect mucous membranes of the mouth and nose from droplet spatter, but they do not provide complete protection against inhalation of airborne infectious agents. There are currently no data available to assess the risk of SARS-CoV-2 transmission during dental practice. To date in the United States, clusters of healthcare personnel who have tested positive for COVID-19 have been identified in hospital settings and long-term care facilities, but no clusters have yet been reported in dental settings or among DHCP.1,2

†Dental healthcare personnel (DHCP) refers to all paid and unpaid persons serving in dental healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including:

Regardless of the degree of community spread, continue to practice universal source control and actively screen for fever and symptoms of COVID-19 for all people who enter the dental facility. If patients do not exhibit symptoms consistent with COVID-19, provide dental treatment only after you have assessed the patient and considered both the risk to the patient of deferring care and the risk to DHCP of healthcare-associated disease transmission. Ensure that you have the appropriate amount of personal protective equipment (PPE) and supplies to support your patient volume. If PPE and supplies are limited, prioritize dental care for the highest need, most vulnerable patients first.

If your community is experiencing no transmission or minimal community transmission*, dental care can be provided to patients without suspected or confirmed COVID-19 using strict adherence to Standard Precautions. However, given that patients may be able to spread the virus while pre-symptomatic or asymptomatic, it is recommended that DHCP practice according to the below considerations whenever feasible. Because transmission patterns can change, DHCP should stay updated about local transmission trends.

If your community is experiencing minimal to moderate† or substantial transmission‡, dental care can be provided to patients without suspected or confirmed COVID-19 using the below considerations to protect both DHCP and patients and prevent the spread of COVID-19 in dental facilities.

Considerations for additional precautions or strategies for treating patients with suspected or confirmed COVID-19 are also included below.

*No to minimal community transmission is defined as evidence of isolated cases or limited community transmission, case investigations underway; no evidence of exposure in large communal setting.

†Minimal to moderate community transmission is defined as sustained transmission with high likelihood or confirmed exposure within communal settings and potential for rapid increase in cases.

‡Substantial community transmission is defined as large scale community transmission, including communal settings (e.g., schools, workplaces).

Telephone triage all patients in need of dental care. Assess the patient’s dental condition and determine whether the patient needs to be seen in the dental setting. Use teledentistry options as alternatives to in-office care.

Request that the patient limit the number of visitors accompanying the patient to the dental appointment to only those people who are necessary.

Advise patients that they, and anyone accompanying them to the appointment, will be requested to wear a face covering when entering the facility and will undergo screening for fever and symptoms consistent with COVID-19.

Systematically assess all patients and visitors upon arrival.

Ensure that the patient and visitors have donned their own face covering, or provide a surgical mask if supplies are adequate.

Ask about the presence of fever or other symptoms consistent with COVID-19.

Ask patient to re-don their face covering at the completion of their clinical dental care when they leave the treatment area.

Even when DHCP screen patients for respiratory infections, inadvertent treatment of a dental patient who is later confirmed to have COVID-19 may occur. To address this, DHCP should request that the patient inform the dental clinic if they develop symptoms or are diagnosed with COVID-19 within 14 days following the dental appointment.

*For the general population, fever is measured as a temperature ≥100.4˚F. Fever may be subjective or confirmed. If the patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other symptoms consistent with COVID-19 are present, care can be provided with appropriate protocols.

Facility Considerations

Take steps to ensure patients and staff adhere to respiratory hygiene and cough etiquette, as well as hand hygiene, and all patients follow triage procedures throughout the duration of the visit.

Post visual alertspdf icon (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) about hand hygiene and respiratory hygiene and cough etiquette. Instructions should include wearing a cloth face covering or facemask for source control, and how and when to perform hand hygiene.

Remove toys, magazines, and other frequently touched objects that cannot be regularly cleaned or disinfected from waiting areas.

Minimize the number of persons waiting in the waiting room.

Patients may opt to wait in a personal vehicle or outside the dental facility where they can be contacted by mobile phone when it is their turn for dental care.

Minimize overlapping dental appointments.

Equipment Considerations

After a period of non-use, dental equipment may require maintenance and/or repair. Review the manufacturer’s instructions for use (IFU) for office closure, period of non-use, and reopening for all equipment and devices. Some considerations include:

Dental unit waterlines (DUWL):

Test water quality to ensure it meets standards for safe drinking water as established by the Environmental Protection Agency (< 500 CFU/mL) prior to expanding dental care practices.

Confer with the manufacturer regarding recommendations for need to shock DUWL of any devices and products that deliver water used for dental procedures.

Continue standard maintenance and monitoring of DUWL according to the IFUs of the dental operatory unit and the DUWL treatment products.

Autoclaves and instrument cleaning equipment

Ensure that all routine cleaning and maintenance has been performed according to the schedule recommended per manufacturer’s IFU.

Test sterilizers using a biological indicator with a matching control (i.e., biological indicator and control from same lot number) after a period of non-use prior to reopening per manufacturer’s IFU.

Administrative Controls and Work Practices

DHCP should limit clinical care to one patient at a time whenever possible.

Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. All other supplies and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination. Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.

Avoid aerosol-generating procedures whenever possible. Avoid the use of dental handpieces and the air/water syringe. Use of ultrasonic scalers is not recommended. Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only).

If aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction and dental dams to minimize droplet spatter and aerosols. The number of DHCP present during the procedure should be limited to only those essential for patient care and procedure support.

Preprocedural mouth rinses (PPMR)

There is no published evidence regarding the clinical effectiveness of PPMRs to reduce SARS-CoV-2 viral loads or to prevent transmission. Although COVID-19 was not studied, PPMRs with an antimicrobial product (chlorhexidine gluconate, essential oils, povidone-iodine or cetylpyridinium chloride) may reduce the level of oral microorganisms in aerosols and spatter generated during dental procedures.

Engineering Controls

Properly maintain ventilation systems.

Ventilation systems that provide air movement from a clean (DHCP workstation or area) to contaminated (clinical patient care area) flow direction should be installed and properly maintained. Providing supply air only in the receptionist area with return air louvers positioned in the waiting area will help to achieve this effect.

Consult a heating, ventilation and air conditioning (HVAC) professional to investigate increasing filtration efficiency to the highest level compatible with the HVAC system without significant deviation from designed airflow.

Consult a HVAC professional to investigate the ability to safely increase the percentage of outdoor air supplied through the HVAC system (requires compatibility with equipment capacity and environmental conditions).

Limit the use of demand-controlled ventilation (triggered by temperature setpoint and/or by occupancy controls) during occupied hours and when feasible, up to two hours post occupancy to assure that ventilation does not automatically change. Run bathroom exhaust fans continuously during business hours.

Consider the use of a portable HEPA air filtration unit while the patient is actively undergoing, and immediately following, an aerosol-generating procedure.

The use of these units will reduce particle count (including droplets) in the room and will reduce the amount of turnover time, rather than just relying on the building HVAC system capacity.

Place HEPA unit within vicinity of patient’s chair, but not behind DHCP. Ensure DHCP are not positioned between the unit and the patient’s mouth. Position the unit to ensure that it does not pull air into or past the breathing zone of the DHCP.

For dental facilities with open floor plans, to prevent the spread of pathogens there should be:

At least 6 feet of space between patient chairs.

Physical barriers between patient chairs. Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure extending barriers to ceiling will not interfere with fire sprinkler systems).

Operatories should be oriented parallel to the direction of airflow if possible.

Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and towards the rear wall when using vestibule-type office layouts.

Patient volume

Determine the maximum number of patients who can safely receive care at the same time in the dental facility, based on the number of rooms, the layout of the facility, and the time needed to clean and disinfect patient operatories*.

*To allow time for droplets to sufficiently fall from the air after a dental procedure, DHCP should wait at least 15 minutes after the completion of dental treatment and departure of the patient to begin the room cleaning and disinfection process.3

Hygiene

Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.

Use ABHR with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHR.

Dental healthcare facilities should ensure that hand hygiene supplies are readily available to all DHCP in every care location.

Universal Source Control

As part of source control efforts, DHCP should wear a facemask at all times while they are in the dental setting.

When available, surgical masks are preferred over cloth face coverings for DHCP; surgical masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.

Cloth face coverings should NOT be worn instead of a respirator or facemask if more than source control is required, as cloth face coverings are not PPE.

Some DHCP whose job duties do not require PPE (such as clerical personnel) may continue to wear their cloth face covering for source control while in the dental setting.

Other DHCP (such as dentists, dental hygienists, dental assistants) may wear their cloth face covering when they are not engaged in direct patient care activities, and then switch to a respirator or a surgical mask when PPE is required.

DHCP should remove their respirator or surgical mask and put on their cloth face covering when leaving the facility at the end of their shift.

DHCP should also be instructed that if they must touch or adjust their mask or cloth face covering, they should perform hand hygiene immediately before and after.

Because facemasks and cloth face coverings can become saturated with respiratory secretions, DHCP should take steps to prevent self-contamination:

DHCP should change facemasks and coverings if they become soiled, damp, or hard to breathe through.

Cloth face coverings should be laundered daily and when soiled.

DHCP should perform hand hygiene immediately before and after any contact with the facemask or cloth face covering.

Dental facilities should provide DHCP with training about when, how, and where cloth face coverings can be used, including frequency of laundering, guidance on when to replace them, circumstances when they can be worn in the facility, and the importance of hand hygiene to prevent contamination.

Dental facilities must ensure that any reusable PPE is properly cleaned, decontaminated, and maintained after and between uses. Dental settings also should have policies and procedures describing a recommended sequence for safely donning and doffing PPE.

DHCP should wear a surgical mask, eye protection (goggles, protective eyewear with solid side shields, or a full-face shield), and a gown or protective clothing during procedures likely to generate splashing or spattering of blood or other body fluids.

During aerosol-generating procedures conducted on patients assumed to be non-contagious, consider the use of an N95 respirator* or a respirator that offers a higher level of protection such as other disposable filtering facepiece respirators, PAPRs, or elastomeric respirators, if available. Respirators should be used in the context of a respiratory protection program, which includes medical evaluations, training, and fit testing. Of note, it is uncertain if respirators with exhalation valves provide source control. If a respirator is not available for an aerosol-generating procedure, use both a surgical mask and a full-face shield. Ensure that the mask is cleared by the US Food and Drug Administration (FDA) as a surgical maskexternal icon. Use the highest level of surgical maskpdf iconexternal icon available. If a surgical mask and a full-face shield are not available, do not perform any aerosol-generating procedures.

Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.

Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.

Perform hand hygiene.

PPE Optimization Strategies

Major distributors in the United States have reported shortages of PPE, especially surgical masks and respirators. The anticipated timeline for return to routine levels of PPE is not yet known. CDC has developed a series of strategies or options to optimize supplies of PPE in healthcare settings when there is limited supply, and a burn rate calculator that provides information for healthcare facilities to plan and optimize the use of PPE for response to the COVID-19 pandemic. Optimization strategies are provided for gloves, gowns, facemasks, eye protection, and respirators.

These policies are only intended to remain in effect during times of shortages during the COVID-19 pandemic. DHCP should review this guidance carefully, as it is based on a set of tiered recommendations. Strategies should be implemented sequentially. Decisions by facilities to move to contingency and crisis capacity strategies are based on the following assumptions:

Facilities understand their current PPE inventory and supply chain;

Facilities understand their PPE utilization rate;

Facilities are in communication with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) regarding identification of additional supplies;

Facilities have already implemented engineering and administrative control measures;

Facilities have provided DHCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care.

For example, extended use of facemasks and respirators should only be undertaken when the facility is at contingency or crisis capacity and has reasonably implemented all applicable administrative and engineering controls. Such controls include selectively canceling elective and non-urgent procedures and appointments for which PPE is typically used by DHCP. Extended use of PPE is not intended to encourage dental facilities to practice at a normal patient volume during a PPE shortage, but only to be implemented in the short term when other controls have been exhausted. Once the supply of PPE has increased, facilities should return to standard procedures.

*A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer’s risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by CDC/National Institute for Occupational Safety and Health (NIOSH), including those intended for use in healthcare.

Respirator use must be in the context of a complete respiratory protection program in accordance with OSHA Respiratory Protection standard (29 CFR 1910.134external icon). DHCP should be medically cleared and fit tested if using respirators with tight-fitting facepieces (e.g., a NIOSH-approved N95 respirator) and trained in the proper use of respirators, safe removal and disposal, and medical contraindications to respirator use.

†Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices (see PPE Optimization Strategies).

Environmental Infection Control

DHCP should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient (however, it is not necessary that DHCP should attempt to sterilize a dental operatory between patients).

To clean and disinfect the dental operatory after a patient without suspected or confirmed COVID-19, wait 15 minutes after completion of clinical care and exit of each patient to begin to clean and disinfect room surfaces. This time will allow for droplets to sufficiently fall from the air after a dental procedure, and then be disinfected properly.3

Routine cleaning and disinfection procedures (e.g., using cleaners and water to clean surfaces before applying an Environmental Protection Agency-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product’s label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.

Refer to List Nexternal icon on the EPA website for EPA-registered disinfectants that have qualified under EPA’s emerging viral pathogens program for use against SARS-CoV-2.

Alternative disinfection methods

The efficacy of alternative disinfection methods, such as ultrasonic waves, high intensity UV radiation, and LED blue light against COVID-19 virus is not known. EPA does not routinely review the safety or efficacy of pesticidal devices, such as UV lights, LED lights, or ultrasonic devices. Therefore, EPA cannot confirm whether, or under what circumstances, such products might be effective against the spread of COVID-19.

CDC does not recommend the use of sanitizing tunnels. There is no evidence that they are effective in reducing the spread of COVID-19. Chemicals used in sanitizing tunnels could cause skin, eye, or respiratory irritation or damage.

DHCP in the room should wear an N95 or higher-level respirator, such as disposable filtering facepiece respirator, powered air-purifying respirator (PAPR), or elastomeric respirator, as well as eye protection (goggles or a full-face shield), gloves, and a gown.

The number of DHCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure.

Aerosol-generating procedures should ideally take place in an airborne infection isolation room.

Consider scheduling the patient at the end of the day.

Do not schedule any other patients at that time.

People with COVID-19 who have ended home isolation can receive dental care following Standard Precautions.

Considerations for Use of Test-Based Strategies to Inform Patient Care

In the context of COVID-19, some infected individuals might not be identified based on clinical signs and symptoms.

Facilities could consider using a tiered approach to universal PPE based on the level of transmission in the community. In areas where there is moderate to substantial community transmission, this includes consideration for DHCP for wearing an N95 or higher-level respirator for patients undergoing procedures that might pose higher risk (e.g., those generating potentially infectious aerosols or involving anatomic regions where viral loads might be higher).

Depending on testing availability and how rapidly results are available, facilities can also consider implementing pre-admission or pre-procedure testing for COVID-19, which might inform implementation of PPE use as described above, especially in the situation of PPE shortages. However, limitations of this approach should be considered, including negative results from patients during their incubation period who could become infectious later, and false negative tests depending on the test method used.

Monitor and Manage Dental Health Care Personnel

Implement sick leave policies for DHCP that are flexible, non-punitive, and consistent with public health guidance.

As part of routine practice, DHCP should be asked to regularly monitor themselves for fever and symptoms consistent with COVID-19.

DHCP should be reminded to stay home when they are ill and should receive no penalties when needing to stay home when ill or under quarantine.

If DHCP develop fever (T≥100.0˚F) or symptoms consistent with COVID-19 while at work, they should keep their cloth face covering or facemask on, inform their supervisor, and leave the workplace.

Screen all DHCP at the beginning of their shift for fever and symptoms consistent with COVID-19*.

Actively measure their temperature and document absence of symptoms consistent with COVID-19.

Clinical judgement should be used to guide testing of individuals in such situations.

Medical evaluation may be warranted for lower temperatures (<100.0˚F) or other symptoms based on assessment by occupational health personnel. Additional information about clinical presentation of patients with COVID-19 is available.

For information on work restrictions for health care personnel with underlying health conditions who may care for COVID-19 patients, see CDC’s FAQ.

*For DHCP, fever is either measured temperature ≥100.0˚F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed, or taking certain medications (e.g., NSAIDs).

Education and Training

Provide DHCP with job- or task-specific education and training on preventing transmission of infectious agents, including refresher training.

Ensure that DHCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and the environment during the process of removing such equipment.

3Baron, P. Generation and Behavior of Airborne Particles (Aerosols). Presentation published at CDC/NIOSH Topic Page: Aerosols, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services, Cincinnati, OH. www.cdc.gov/niosh/topics/aerosols/pdfs/Aerosol_101.pdfpdf icon.